Present and future role of PGS according to different...

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PCC 1: “Clinical aspects of PGD/PGS”

Present and future role of PGS according to different clinical

indications Anna Pia Ferraretti, Cristina Magli ,

Luca GianaroliSISMER- Bologna - Italy

IVF population at higher risk to produce aneuploidembryos ( “poor rognoosis patients”):

advanced maternal age ( AMA)

recurrent idiopathic miscarriage (RM)

recurrent implantation failure (RIF)

association of two factors

( severe male factor - SMF)

( POR)

Classical indications for PGS

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Aneuploidy rates

Fragouli et al,2009, Kilani et al, 2014,Verpoest et al 2008, Kuliev et al 2008, Gianaroli et al 2011

Since the high incidence of aneuploidies in these population, the biological rationale to select euploidembryos (PGS) does sound very logical to increase the performance of ART

PGS in ART

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Clinical impact of PGS

Very controversial issue

First generation PGS (FISH on day

3 embryos)

FISH

Preimplantation genetic screening: a systematic rev iew and meta-analysis of RCTs on the effect of PGS on LBR. Mastenbroek et a lHum Reprod Update 2011;17:454–4 66.

Cleavage stage

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Factors affecting results in PGS first generation

Mosaicism5.6-5.7%

Limited number of

chromosomes

Less potential of the embryo to implant

PGS new generations

The present

More DNA: less no results

Less mosaicism

Reduced ( no) impact on embryo implantation

Blastocentesis

The future

arrayCG

NGS

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Aneuploidy rate per cromosome (CGHa)

CGH on polar bodies ( SISMER) inAMA, RIF and RM populations

Gianaroli et al 2013

Clinical impact of PGS


Higher potential effect but the clinical value has

yet to be determined

First generation PGS (FISH on day 3

embryos)

New generations PGS

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PGS clinical aspectsHow to produce evidence ?

Gold standard : Large, Prospective Randomized Trials (very few studies)

Retrospective, observational studies

Meta-analysis

PGS clinical aspects in classical indicationsHow to compare PGS vs no-PGS?

End-points PGS No-PGS Comments pro and

cons

Starting point to

compare

Egg retrieval Egg retrieval

Transferred cycles (%) 50-60% 80-90% Avoid ( further)

unsuccessful transfers

( mosaicism??)

Clinical pregnancy and

implantation rates

Higher with PGS by CGH

on blastocysts ?

Miscarriages rate Lower Higher

LBR / transfer Higher Lower It is a correct indicator?

Cumulative ( fresh and

frozen) LBR/ egg

retrieval

Shorter time to delivery

with PGS

Reduced costs ??


with FISH on day 3 embryos

Similar

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PGS clinical aspects in classical indicationsHow to compare PGS vs no-PGS?

End-points PGS No-PGS Comments pro and

cons

Starting point Egg retrieval Egg retrieval

Transferred cycles (%) 50-60% 80-90% Avoid ( further)

unsuccessful transfers.

Mosaicism?

Clinical pregnancy and

implantation rates

Similar /Higher with PGS

on blastocysts ?

Miscarriages rate Lower Higher

LBR / transfer Higher Lower It is a correct indicator?

Cumulative ( fresh and

frozen) LBR/ egg

retrieval

Shorter time to delivery

with PGS

Reduced costs ??

Reduced by day 3 embryo

biopsy (?)

Similar

IVF population at higher risk to produce aneuploidembryos:

advanced maternal age ( AMA)recurrent idiopathic miscarriage (RM)


severe male factor (SMF)


( POR)


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Effect of maternal age on euploidy rates( 46,439 embryos analyzed by aCGH)

Demko et al, Fertil Steril 2016

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PGS for AMA : from which age ?

15.169 consecutive trophectoderm biopsies and aCGH

Franasiak et al, Fertil Steril 2013


15.169 consecutive trophectoderm biopsies


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15.169 consecutive trophectoderm biopsies


REDUCED OVARIAN RESERVE

Wallace Kelsey Model

Wallace and Kelsey. Human Ovarian Reserve from Conc eption to the Menopause PLoS One. 2010; 5(1): e8772.

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Munné et al., ASRM 2015

# of

embryos

egg

donors

<35

years

35-37

years

38-40

years

41-42

years

>42

years

1-3 83% 80% 71% 57% 36% 22%

4-6 97% 95% 92% 82% 59% 43%

7-10 99% 98% 96% 89% 74% 50%

10-17 100% 99% 99% 97% 88% banked 64% banked

>17 100% 100% 100% 99% 97% banked 87% banked

Cumulative number of blastocyst needed to produce a t least one euploid blastocyst

% of patients with normal blastocysts

Conclusions:- In women 35 and older more than 50% of embryos are chromosomally abnormal - Women 41 and older need 18 or more embryos to secu re one euploid one- Of those with no euploid embryos in the first cycl e, 38% (41-42 years old) and 25% (> 42 yeas old), those that produced 17 embryos produced euploid embryos in successive cycles.

FISH for PGS: Randomized clinical trials

Lower LBR/women with PGS

Mastenbroek et al., Preimplantation genetic screeni ng: a systematic review and meta-analysis of RCTs. Hum Reprod Update 2011;17:454–466.

Cleavage stage

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PGS in AMArecent RCT by FISH on day 3

Moayeri 2016Women > 35yrs-150 cycles

Rubio 2013Women ≥40 yrs- 183 cycles

P<0.01

PGS in AMARetrospective studies by CGH on

blastocysts

Lee Hl et al, 2015Women 40-43 yrs – 620 cycles

P<0.01

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5741 cycles - mostly done by aCGH on day 5

Age < 35 yrs : PGS was not associated to improved clinical pregnancy or Live birth ratesAge ≥ 35 yrs : PGS was associated withlower odds of miscarriage per pregnancyAge > 37 yrs : higher likelihood of having a live birth delivery per transfer

Outcomes of IVF with PGS : an analysis of the US ART 2011-2012 ( FS 2015)

Can full karyotyping increase the efficacy compared toFISH ?

PGS in AMA

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FREQUENCY OF ANEUPLOIDY IN OOCYTES ACCORDING TO AGE

%

No. observations= 5.650

≤35 36-37 38-39 40-42 ≥43 yrs

CHROMOSOMAL ANALYSIS ON OOCYTES

0

5

10

15

20

25

30

1316182122

aP<0.005

bP<0.05cP<0.025

a

a

b

b

c

c



recurrent idiopathic miscarriage (RM)recurrent implantation failure (RIF)



( POR)


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Couples with RM have an expected miscarriage rate of 33.5%

The % of euploid embryos by PGS is 35%

PGS reduces the miscarriage rate to < 10% ( observational studies)

Very poor data comparing IVF with and without PGS

PGS in idiopathic RM ( age < 40 yrs)

IVF PGS Expectant

management

LBR 40% 55%

Miscarriage rate 7% 25%

Time to delivery Higher

Emotional distress of RM Lower

Cost per Live Birth 43.300 418

Murugappan et al, Fertil Steril 2015

Can full karyotyping increase the results compared to FISH ?The chromosomeschosen for FISH analyses ( 13,15,16,18,21,22 ) were those more involved in spontaneous miscarriages

PGS in idiopathic RM ( age < 40 yrs)

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( POR)


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Failure of implantation after :

≥ 3 embryo transfers with high-quality embryos

or

the transfer of ≥ 10 embryos in multiple transfers ( exact

number to be determined by each centre)

Harton et al, Hum Reprod 2011, 26;14-24

ESHRE PGD Consortium Definition of RIF - 2011

Female age < 40 yrs,normal ovarian response,

± male factor

RECURRENT IMPLANTATION FAILURE PATIENTS

Heterogeneous population

Numerous factors involved in RIF

Altered Karyotype

Uterine anomalies

Endometrial anomalies

Advanced Maternal

Age

Coagulation defects

Immunological reactions

Sperm contribution

Geneticfactor

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RIF ± Advanced maternal age (AMA)or severe male factor

Aneuplidies on embryos +3%

DATA FROM THE LITERATUREPGS in RIF Technique applied

Patientswith RIF enrolled

normal embryos

(%)

Imp. Rate (PGS vs control)

Pregn. rate (PGS vs control)

Live birth rate (PGS

vs control)

Gianaroli et al., 1997

blastomere FISH

(X,Y,13,18,21)20

18/40(45%)

11.1% vs 4.1%

28.6% vs 16.7%

not reported

Gianaroli etal., 1999

blastomereFISH(X,Y,13,14,15,

16,18, 21,22)54

64/138(46%)

17.3% vs 9.5%

25% vs 22%not

reported

Kahraman et al., 2000

blastomereFISH

(X,Y,13,18,21)23 54% ? 30.4%

not reported

Gianaroli et al., 2002


16,18,21,22)66

143/356(40%)

20.5% 28.8% 27%

Werlin et al., 2003


17,18,21,22)19

9/28(32.1%)

? 20% vs 0%not

reported

Pehlivan, 2003

blastomereFISH (X,Y,13,16,18,21,22)

3691/263(34.6%)

24.6% vs 24.1%

40.7% vs 33.3%

notreported

El Toukhy, 2005

polar bodiesFISH (13,16,

18,21,22)116

not reported

24% vs 12% 43% vs 25%not

reported

Yakin et al., 2008


140not

reported11.9% vs

18.4%14.8% vs

26.8%14.8% vs

24.4%

Blockeel etal., 2008


200not

reported21.4% vs

25.3%32.7% vs

42.9%20.8% vs

40.2%

Rubio et al., 2012

blastomereFISH

(X,Y,13,15,16,17,18,21,22)

91not

reportednot reported

37.3% vs 20.8%

47.9% vs 27.9%

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FISH for PGD: Randomized clinical trials

No difference in live birth ratewhen correcting for statisticalheterogeneity.

Mastenbroek et al., Preimplantation genetic screeni ng: a systematic review and meta-analysis of RCTs. Hum Reprod Update 2011;17:454–466.

Cleavage stage

Aneuploidy rate per cromosome (CGHa)

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Magli et al., Fertil Steril 2010. In press.

After completion of the treatment cycle by conventional FISH,PB1s of the transferred embryos were reanalyzed for chromosomes 1, 4

and ( second panel)

13 15 16 18 21 22

1st

panel

1 4 6

2nd

panel

Aneuploidy of chromosomes 1, 4 and 6

Retrospective observational study

Fertility and Sterility 2010

Abnormal conditions of these large chromosomes can allow normal early embryo development but no implantation

or, should if happens, very early miscarriage occurs (before pregnancy detection)

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GCH selection for RIF( Greco et al, 2014)

Study design :Prospective, self randomization76 Women < 36 yrs with an history of 3-9 (mean4.9) previous IVF attempts

PGS No PGS

Embryo policy eSET DET

Euploidy rate 46% ---

Clinical PR/women 68% 22% P < 0.001

Miscarriages 0 0

FISH on semen

SISMER policy in RIF( 2013-2014)

Normal

aCGH –PGS

on polar bodies

Altered

aCGH-PGS

on embryos

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PGSon oocytes

(no male genetic factor)

Patients 47

Age (yrs) 37.8

n. of MII collecetdoocytes

397

n. of 2PN biopsied 301

n. of day 3 viableembryos

198

n.of oocytes analyzed 198

n. euploid 65 (34%)

aCGH in RIF Material

Patients 47

Number of transfers 26 (55%)

Mean embryos transferred 1.4

Clinical pregnancies 13

Implantation rate 48% (17/35)

Miscarriages 1

LBR/patient 25.5%

LBR/ET 46%

PGS on oocytes in RIF (no male genetic factor) Outcome

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Proportion of aneuploidy

% of patients

Proportion of aneuploid oocytes

Different sub-populations of patients

LBR/patient in relation to the proportion of aneuploidy

% of patients


Population of RIF with an high incidence of aneuploidy (50-100%)

No transferLBR 55%

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LBR/patient in relation to the proportion of aneuploidy

% of patients


No transfer

LBR 24%

Population of RIF with low incidence of aneuploidy but lower

LBR after transfer of good morphology and euploid embryos :

no genetic factor for RIF

Patients 20

Euploid embryos 23 (24%)

Number of transfers 8 (40%)

Mean embryos transferred 1.2

Clinical pregnancies 2

Miscarriages 1

LBR/patient 5%

LBR/ET 12.5%

PGS by CGH on embryos inRIF + severe male factor

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IVF population at higher risk to produce aneuploid embryos ( “poor prognosis patients”) to improve outcomesadvanced maternal age ( AMA)




( severe male factor - SMF)

( POR)


New indications ?

PGS : new indication ?


Good prognosis women : no more than 1 previous cycle, up to 42 yrs but with a normal ovarian reserve

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Blastocyst biopsy with CCS significantly increases IVF implantation and delivery rate :

a randomized controlled trial

Scott et , Fertil Steril 2013

Women 21-42 yrs (including oocyte donors) with a normal ovarian reserve

%

Mean embryo transferred 2.0 ±0.2Twin deliveries : 30%

PGS : new and point ?

Good prognosis women up to 42 yrs but with a normal ovarian response

To reduce the risk of multiple pregnancies

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IVF with single euploid blastocyst transfer : a randomized controlled trial

Forman et al, Fertil Steril 2013

Women <43 yrs with a normal ovarian reserve eSET after PGS ( CCS) vs DET without PGS

PGS in AMARetrospective studies by CGH on

blastocysts

Ubaldi et al 2015Women > 35 yrs

eSET after PGS vs conventional transfer (2.9±1 bl astocysts)

P<0.01 P<0.01

Reduction of the multiple pragnancy rate with eSET by PGS in advanced maternal age population

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PGS : new end point

To increase the performance of eSET

in young patients

Selection of single blastocysts for fresh transfer via standard morphology or with aCGH for good prognosis patients : a randomized pilot study

Young et al, Mol Cytogenetics 2012

103 women - Age < 35

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FISH

Preimplantation genetic screening: a systematic rev iew and meta-analysis of RCTs on the effect of PGS on LBR. Mastenbroek et a lHum Reprod Update 2011;17:454–4 66.

Cleavage stage

Fertility and Sterility, December 2015

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PGS : the future

Good prognosis patients

Euploid eSET (?)

The highest probability of thebirth of a single ( healthy) baby

To increase safetyTo increase accuracy ( mosaicism?)

To reduce costs

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“Acceptable costs for the patient and society”Chambers et al, Fertil Steril 2013,100.319

“Under some circumstances, ART represents good valuesof money from a social perspective :

the monetary values of providing ART treatments can be far covered by the revenue of ART children”

“These clinical circumstances are if babies born as singleton”

PGS : the future

Good prognosis patients

To increase safetyTo increase accuracy ( mosaicism?)

To reduce costs

Euploid eSET

The highest probability of thebirth of a single ( healthy) baby

Poor prognosis patients

To avoid unsuccessful transfers To reduce the rate of miscarriages

To shorten the time to deliveryTo reduce the risk of multiple pregnancies

Present and future role of PGS according to different...

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